Fill and Sign the Form 100 00247s Complaint for Order Against Stalking Vermont

100 - 00247 - Compla int for Order Aga ins t Sta lking or Sexua l As s ault (07/2016) Pa ge 1 of 2 S TATE OF V ERMONT SUPERIOR COURT CIVIL DIVISION Unit Docket No. Plaintiff (s) Defendant (s) vs. Complaint for Order Against Stalking or Sexual Assault Plaintiff’s Information: Name: ___________ __ __ __ __ ___ __ __ __ __ __ __ __ ___ __ _ Date of Birth : ____________ __ __ __ __ __ _ Name(s) of minor child( ren ) : ___________ __ __ ___ __ _ ___________ __ __ ___ __ __ _ ___________ __ __ ___ __ _ ___________ __ __ ___ __ __ _ Defendant’s Information: Name : ___________ __ __ __ __ ___ __ __ __ __ __ __ __ ___ __ _ Date of Birth : ____________ __ __ __ __ __ _ Address: ____________ __ __ __ __ ___ __ __ __ __ __ __ __ ___ __ __ __ __ __ __ __ ___ __ __ __ __ __ __ __ ___ __ __ Relationship of the Parties : ☐ Married to each other ☐ Live in same residenc e ( current or past) ☐ Divorced from each other ☐ Sexual relationship ( current or past) ☐ Dating each other ( current or past) ☐ Other (describe relations hip) ___________________________________________________________ ☐ Family members (describe rela tionship) ______________ ___ __ __ __ __ __ __ __ ___ __ __ __ __ __ __ __ __ Other Civil/Probate/Juvenile/Criminal Court Proceedings or Orders Involving These Parties : Proceeding : ☐ Pending Order ☐ Existing Order Name of Court : County : __________ _____ __ State : ___________ __ Attorney : __________ __ ___ __ __ __ __ __ __ __ I. STALK ING ☐ On more than one occasion, on or about ___________ __ __ __ _ and __________ __ ___ __ __ , the Defendant purposefully did one or more of the following to : ☐ Plaintiff ☐ Plaintiff’s child ( ren) : ☐ followed, monitored, or surveilled ☐ threatened or made threats ☐ interfered with property II. SEXUAL ASSAULT ☐ 1. On or about ___________ __ __ ___ __ __ , the Defendant sexually assaulted the Plaintiff or the Plaintiff's c hild(ren) by doing one or more of the following: ☐ lewd and lascivious conduct ☐ lewd and lascivious conduct with a child ☐ sexual assault ☐ aggravated sexual assault ☐ use of a child in a sexual performance ☐ consenting to a sexual performance and Plaintif f was the victim of the offense 100 - 00247 - Compla int for Order Aga ins t Sta lking or Sexua l As s ault (07/2016) Pa ge 2 of 2 ☐ 2. On ___________ __ __ __ __ __ __ _ , the Defendant was convicted of sexually assaulting the Plaintiff. III. REQUEST FOR RELIEF The Plaintiff requests the Court: ☐ Order the Defendant to stay away from ____________ __ __ __ __ __ __ __ ___ __ __ __ __ __ __ __ ___ __ ☐ Other: ☐ I am asking for an emergency order before the Defendant is notified and a hearing is held because: The facts to support this request for protection order can be found on Plaintiff’s accompanying affidavit. Dated _____________________________ ___________________________________ Si gna ture of Pl aintiff/Attorney